Plan Year 2017 Prior Authorization (PA) Criteria Prior Authorization: Commonwealth Care Alliance requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from Commonwealth Care Alliance before you fill your prescriptions. If you don t get approval, Commonwealth Care Alliance may not cover the drug. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT OUR PRIOR AUTHORIZATION CRITERIA. Commonwealth Care Alliance (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees. You can get this document in Spanish, or speak with someone about this information in other languages for free. Call 1-866-610-2273. The call is free. Este documento está disponible en español. Para hablar con un intérprete, por favor llame al 1-866-610-2273. Este es un servicio gratuito. Last updated 09/01/2017
2017 Commonwealth Care Alliance (Medicare-Medicaid Plan) One Care Plan Products Affected ARALAST 500MG INJ GLASSIA 1000MG/50ML INJ PROLASTIN 1000MG INJ ZEMAIRA 1000MG INJ IgA deficiency with known anti-iga antibody 12 months 1
adapalene 0.1% cream adapalene 0.3% gel tretinoin 0.025% cream tretinoin 0.04% gel tretinoin 0.05% gel tretinoin 0.1% gel adapalene 0.1% gel tretinoin 0.01% gel tretinoin 0.025% gel tretinoin 0.05% cream tretinoin 0.1% cream 2
ADCIRCA 20MG TAB Diagnosis confirmed by right heart catheterization. 3
chorionic gonadotropin 10000unit inj megestrol acetate 125mg/ml susp MEGACE 625MG/5ML SUSP SEROSTIM INJ Covered Uses All FDA-approved indications not otherwise covered under Part D. 4
ADEMPAS 0.5MG TAB ADEMPAS 1MG TAB ADEMPAS 2MG TAB ADEMPAS 1.5MG TAB ADEMPAS 2.5MG TAB Diagnosis confirmed by right heart catheterization. Restricted to or in consult with Pulmonologist or Cardiologist. For diagnosis of Pulmonary Arterial Hypertension, trial of one (1) of the following: Letairis, Opsumit or Tracleer. For diagnosis of Persistent/recurrent Chronic Thromboembolic Pulmonary Hypertension (CTEPH) (WHO Group 4), trial of prior therapy is not required. 5
AFINITOR 10MG TAB (New Starts Only) AFINITOR 2MG SUSP (New Starts Only) AFINITOR 5MG SUSP (New Starts Only) AFINITOR 7.5MG TAB (New Starts Only) AFINITOR 2.5MG TAB (New Starts Only) AFINITOR 3MG SUSP (New Starts Only) AFINITOR 5MG TAB (New Starts Only) 6
ALECENSA 150MG CAP (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 7
ALUNBRIG 30MG TAB (New Starts Only) Prescribed by, or in consultation with an Oncologist. 8
AMPYRA 10MG ER TAB Restricted to or in consult with Neurology Specialist. 9
TESTOSTERONE 1% (25MG) GEL TESTOSTERONE 1% GEL PUMP TESTOSTERONE 1% (50MG) GEL One (1) morning testosterone level falls below the normal range for a healthy adult male. Patient must have tried and failed ANDRODERM and ANDROGEL. For patients on testosterone replacement therapy, documentation of at least one (1) morning testosterone level from the last 12 months is required. 10
ANDRODERM 2MG/24HR PATCH ANDROGEL 1% (25MG) GEL ANDROGEL 1.62% (1.25GM) GEL ANDROGEL 1.62% GEL testosterone enanthate 200mg/ml inj ANDRODERM 4MG/24HR PATCH ANDROGEL 1% (50MG) GEL ANDROGEL 1.62% (2.5GM) GEL testosterone cypionate 100mg/ml inj Two morning testoterone levels fall below the normal range for a healthy adult male. For patients on testosterone replacement therapy, documentation of at least one (1) morning testosterone level from the last 12 months is required. 11
APTIOM 200MG TAB (New Starts Only) APTIOM 600MG TAB (New Starts Only) APTIOM 400MG TAB (New Starts Only) APTIOM 800MG TAB (New Starts Only) 12
ARCALYST 220MG INJ Prescribed by, or in consultation with, a Rheumatology Specialist, Dermatologist, or Immunologist. 13
fondaparinux sodium 12.5mg/ml (0.4ml) syringe fondaparinux sodium 12.5mg/ml (0.8ml) syringe fondaparinux sodium 12.5mg/ml (0.6ml) syringe fondaparinux sodium 5mg/ml syringe Covered Uses All medically accepted indications not otherwise excluded from Part D. Body weight less than 50 kg (venous thromboembolism prophylaxis only) Patient has history of Heparin Induced Throbmocytopenia (HIT) or HIT is medically suspected. Or, prescribed for prevention or treatment of DVT in an orthopedic surgery patient. 14
ELIDEL 1% CREAM tacrolimus 0.1% ointment tacrolimus 0.03% ointment Trial and failure of two (2) formulary topical corticosteroids. 15
ABILIFY 300MG MAINTENA INJ (New Starts Only) ABILIFY 400MG MAINTENA PF SYRINGE (New Starts Only) aripiprazole 15mg odt (New Starts Only) ARISTADA 441MG/1.6ML SYRINGE (New Starts Only) ARISTADA 882MG/3.2ML SYRINGE (New Starts Only) FANAPT 12MG TAB (New Starts Only) FANAPT 2MG TAB (New Starts Only) FANAPT 6MG TAB (New Starts Only) FANAPT TITRATION PACK (New Starts Only) INVEGA 156MG/ML SYRINGE (New Starts Only) INVEGA 273MG/0.875ML SYRINGE (New Starts Only) INVEGA 410MG/1.315ML SYRINGE (New Starts Only) INVEGA 78MG/0.5ML SYRINGE (New Starts Only) LATUDA 120MG TAB (New Starts Only) LATUDA 40MG TAB (New Starts Only) LATUDA 80MG TAB (New Starts Only) paliperidone 3mg er tab (New Starts Only) paliperidone 9mg er tab (New Starts Only) REXULTI 0.5MG TAB (New Starts Only) REXULTI 2MG TAB (New Starts Only) REXULTI 4MG TAB (New Starts Only) RISPERDAL 25MG INJ (New Starts Only) RISPERDAL 50MG INJ (New Starts Only) SAPHRIS 2.5MG SL TAB (New Starts Only) VRAYLAR 1.5/3MG MIXED PACK (New Starts Only) VRAYLAR 3MG CAP (New Starts Only) VRAYLAR 6MG CAP (New Starts Only) ABILIFY 300MG MAINTENA PF SYRINGE (New Starts Only) aripiprazole 10mg odt (New Starts Only) ARISTADA 273MG/ML SYRINGE (New Starts Only) ARISTADA 662MG/2.4ML SYRINGE (New Starts Only) FANAPT 10MG TAB (New Starts Only) FANAPT 1MG TAB (New Starts Only) FANAPT 4MG TAB (New Starts Only) FANAPT 8MG TAB (New Starts Only) INVEGA 117MG/0.75ML SYRINGE (New Starts Only) INVEGA 234MG/1.5ML SYRINGE (New Starts Only) INVEGA 39MG/0.25ML SYRINGE (New Starts Only) INVEGA 546MG/1.75ML SYRINGE (New Starts Only) INVEGA 819MG/2.625ML SYRINGE (New Starts Only) LATUDA 20MG TAB (New Starts Only) LATUDA 60MG TAB (New Starts Only) paliperidone 1.5mg er tab (New Starts Only) paliperidone 6mg er tab (New Starts Only) REXULTI 0.25MG TAB (New Starts Only) REXULTI 1MG TAB (New Starts Only) REXULTI 3MG TAB (New Starts Only) RISPERDAL 12.5MG INJ (New Starts Only) RISPERDAL 37.5MG INJ (New Starts Only) SAPHRIS 10MG SL TAB (New Starts Only) SAPHRIS 5MG SL TAB (New Starts Only) VRAYLAR 1.5MG CAP (New Starts Only) VRAYLAR 4.5MG CAP (New Starts Only) 16
Patient has tried and failed or was intolerant to 2 of the following for each indication: Bipolar Disorder: aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone. Schizophrenia: aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone. Irritability with Autistic Disorder: aripiprazole, risperidone. Patient has tried and failed or was intolerant to 1 of the following for each indication: Bipolar Depression: olanzapine. Major Depressive Disorder: aripiprazole. Tourette Syndrome: aripiprazole. Acute Manic/Mixed Episodes with Bipolar Disorder: aripiprazole. No trials required for the following indications: Schizoaffective Disorder. 17
AUBAGIO 14MG TAB AUBAGIO 7MG TAB For use in Multiple Sclerosis (MS), patient has a relapsing form of Multiple Sclerosis (MS). Prescribed by a neurologist or a Multiple Sclerosis (MS) specialist. For use in MS, patient has a relapsing form of MS and patient has tried dimethyl fumarate (Tecfidera) AND one of the following: beta-1a (Avonex), peginterferon beta-1a (Plegridy), or glatiramer (Copaxone). Exceptions to having tried an interferon product or glatiramer acetate (Copaxone) can be made if the patient is unable to administer injections due to dexterity issues or visual impairment. 18
BELEODAQ 500MG INJ (New Starts Only) Prescribed by or in consult with Oncology Specialist. 19
BENLYSTA 120MG INJ BENLYSTA 400MG INJ Receiving other biologic therapy or intravenous cyclophosphamide Diagnosis of active, autoantibody-positive (acceptable assays include ANA, anti-ds-dna, anti-sm, etc.) systemic lupus erythematosus AND patient is currently receiving one or more of the following standard therapies: corticosteroids, antimalarials, NSAIDs, immunosuppressants 18 years of age or older 12 months 20
BOSULIF 100MG TAB (New Starts Only) BOSULIF 500MG TAB (New Starts Only) Prescribed by or in consult with Oncology Specialist. 21
BRIVIACT 100MG TAB (New Starts Only) BRIVIACT 10MG/ML INJ (New Starts Only) BRIVIACT 25MG TAB (New Starts Only) BRIVIACT 75MG TAB (New Starts Only) BRIVIACT 10MG TAB (New Starts Only) BRIVIACT 10MG/ML ORAL SOLN (New Starts Only) BRIVIACT 50MG TAB (New Starts Only) 22
CABOMETYX 20MG TAB (New Starts Only) CABOMETYX 60MG TAB (New Starts Only) CABOMETYX 40MG TAB (New Starts Only) Prescribed by or in consultation with Oncology Specialist. 23
CAPRELSA 100MG TAB (New Starts Only) CAPRELSA 300MG TAB (New Starts Only) Prescribed by an Oncologist or Endocrinologist or under the direct consultation of an Oncologist or Endocrinologist 24
CARBAGLU 200MG SUSP 25
CAYSTON 75MG INH SOLN Restricted to or in consult with Infectious Disease or Pulmonology Specialist. 26
CHOLBAM 250MG CAP CHOLBAM 50MG CAP Prescribed by, or in consultation with, a hepatologist or pediatric gastroenterologist. Initial will be 3 months, then if criteria is met approved for the rest of the plan year. Renewal requires documentation of stable or improved liver function. 27
CIMZIA 200MG INJ CIMZIA 200MG/ML SYRINGE For RA, psoriatic arthritis, and ankylosing spondylitis requires intolerance to or failure of therapy etanercept (Enbrel) AND adalimumab (Humira). For Crohn's disease requires a trial of adalimumab (Humira). For RA, psoriatic arthritis, and ankylosing spondylitis, must be prescribed by Rheumatology Specialist. For Crohn's Disease, must be prescribed by Gastroenterology Specialist. 28
CINRYZE 500UNIT INJ FIRAZYR 30MG/3ML SYRINGE 29
COLCHICINE 0.6MG TAB If for gout, trial of Mitigare required. If for Familial Mediterranean fever, trial of Mitigare is not required. 30
COMETRIQ 100MG DAILY DOSE CARTON PACK (New Starts Only) COMETRIQ 60MG DAILY DOSE CARTON PACK (New Starts Only) COMETRIQ 140MG DAILY DOSE CARTON PACK (New Starts Only) Prescribed by or in consult with Oncology Specialist. 31
CORLANOR 5MG TAB CORLANOR 7.5MG TAB The patient is on a maximally tolerated dose of beta blocker or has a history of a documented intolerance, contraindication, or a hypersensitivity to beta blocker. Prescribed by, or in consultation with, a Cardiology Specialist. 32
COSENTYX 150MG/ML AUTO-INJECTOR COSENTYX 150MG/ML SYRINGE Intolerance to or failure of therapy with Humira Psoriatic Arthritis and Ankylosing Spondylitis: Prescriber must be a Rheumatologist. Plaque Psoriasis: Prescriber must be a Dermatologist. 33
COTELLIC 20MG TAB (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 34
CYRAMZA 100MG/10ML INJ (New Starts Only) CYRAMZA 500MG/50ML INJ (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 35
CYSTAGON 150MG CAP CYSTAGON 50MG CAP Prescribed by, or in consultation with, an Endocrinologist, Geneticist, or Metabolic Specialist. 36
CYSTARAN 0.44% OPHTH SOLN For the treatment of corneal cystine crystal accumulation in patients with cystinosis Prescribed by or in consultation with an Ophthalmologist or Geneticist. 37
DARZALEX 100MG/5ML INJ (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 38
methamphetamine 5mg tab 39
dronabinol 10mg cap dronabinol 5mg cap dronabinol 2.5mg cap Diagnosis of loss of appetite due to AIDS OR chemotherapy induced nausea and vomiting This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 40
EMPLICITI 300MG INJ (New Starts Only) EMPLICITI 400MG INJ (New Starts Only) Prescribed by an Oncology Specialist or Hematology Specialist, or in consultation with an Oncology Specialist or Hematology Specialist. 41
ENBREL 25MG INJ ENBREL 50MG/ML SURECLICK INJ ENBREL 25MG/0.5ML SYRINGE ENBREL 50MG/ML SYRINGE For moderate to severe RA or Psoriatic Arthritis requires Trial of or failure of therapy with methotrexate (at least 20mg/wk). Plaque Psoriasis: Trial of, or intolerance to, methotrexate at a dose of 15mg/week or trial of, or intolerance to, soriatane. Rheumatoid Arthritis, Psoriatic Arthritis and Ankylosing Spondylitis: Prescriber must be a Rheumatologist. All Plaque Psoriasis: Prescriber must be a Dermatologist. Approved for the duration of contract year subject to formulary change and member eligibility. 42
ENTRESTO 24-26MG TAB ENTRESTO 97-103MG TAB ENTRESTO 49-51MG TAB Prescribed by, or in consultation with a Cardiology Specialist. 43
EPCLUSA 400-100MG TAB 1) Patient is diagnosed with chronic HCV (greater than 6 months) with genotype indicated 2) Current HCV-RNA titer 3) Documentation that member does or does not have cirrhosis 4) Previous Hepatitis C Treatments Member must be 18 years of age or older Prescribed by, or in consultation with, a Gastroenterologist, Hepatologist, Infectious Disease or Transplant Specialist Coverage duration of 12 weeks. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. For genotypes 1 and 4 only, failure or intolerance to Harvoni and Zepatier are required. For genotypes 5 and 6 only, failure or intolerance to Harvoni is required. 44
ERIVEDGE 150MG CAP (New Starts Only) Prescribed by or inconsultation with Oncology Specialist or Dermatologist. Covered for duration of plan year subject to formulary change and member eligibility. 45
ERWINAZE 10000UNIT INJ (New Starts Only) Restricted to Oncology Specialists or in consult with Oncology Specialist. 46
EXONDYS 100MG/2ML INJ EXONDYS 500MG/10ML INJ 47
FARYDAK 10MG CAP (New Starts Only) FARYDAK 20MG CAP (New Starts Only) FARYDAK 15MG CAP (New Starts Only) Prescribed by an Oncology or Hematology Specialist or in consultation with an Oncology or Hematology Specialist. 48
FERRIPROX 100MG/ML ORAL SOLN FERRIPROX 500MG TAB Restricted to Hematology Specialists or in consult with Hematology Specialist. 49
FIRMAGON 120MG INJ (New Starts Only) FIRMAGON 80MG INJ (New Starts Only) Prescribed by or in consultation with Oncologist or Urologist Approval subject to BvD determination 50
FOLOTYN 40MG/2ML INJ (New Starts Only) Prescribed by or on consultation with Hematologist or Oncologist Approval subject to BvD determination. 51
FORTEO 600MCG/2.4ML PEN INJ Member has had at least 1 fracture, OR member has BMD screening results of -2.5 or below, OR member has previously used and failed a bisphosphonate. 52
FYCOMPA 0.5MG/ML SUSP (New Starts Only) FYCOMPA 12MG TAB (New Starts Only) FYCOMPA 4MG TAB (New Starts Only) FYCOMPA 8MG TAB (New Starts Only) FYCOMPA 10MG TAB (New Starts Only) FYCOMPA 2MG TAB (New Starts Only) FYCOMPA 6MG TAB (New Starts Only) 53
GATTEX 5MG INJ Diagnosis of short bowel syndrome with less than 200cm of remnant functional intestine. Dependent on parenteral support for at least 12 months and at least 3 days per week. 54
GILENYA 0.5MG CAP For use in Multiple Sclerosis (MS), patient has a relapsing form of MS. Prescribed by a neurologist or a Multiple Sclerosis (MS) specialist. For use in MS, patient has a relapsing form of MS and patient has tried dimethyl fumarate (Tecfidera) AND one of the following: beta-1a (Avonex), peginterferon beta-1a (Plegridy), or glatiramer (Copaxone). Exceptions to having tried an interferon product or glatiramer acetate (Copaxone) can be made if the patient is unable to administer injections due to dexterity issues or visual impairment. 55
GILOTRIF 20MG TAB (New Starts Only) GILOTRIF 40MG TAB (New Starts Only) GILOTRIF 30MG TAB (New Starts Only) Prescribed by or in consultation with an Oncology Specialist 56
imatinib 100mg tab (New Starts Only) imatinib 400mg tab (New Starts Only) Prescribed by Oncologist or Hematologist, or under the direct consultation with an Oncologist or Hematologist. 57
NORDITROPIN 10MG/1.5ML PEN INJ NORDITROPIN 30MG/3ML PEN INJ NORDITROPIN 15MG/1.5ML PEN INJ NORDITROPIN 5MG/1.5ML PEN INJ The criteria for approval of growth hormones in adults require the diagnosis of Somatropin Deficiency Syndrome (defined by failure to stimulate Growth Hormone secretion (peak GH level of 10mcg/L or less) by one of the acceptable provocative tests). This may include adults who as children had Growth Hormone deficiency or adults with known pituitary disease. 58
HARVONI 90-400MG TAB 1) Patient is diagnosed with chronic HCV (greater than 6 months) with genotype indicated 2) Current HCV-RNA titer 3) Documentation that member does or does not have cirrhosis 4) Previous Hepatitis C Treatments Member must be 18 years of age or older Prescribed by, or in consultation with, a Gastroenterologist, Hepatologist, Infectious Disease or Transplant Specialist Coverage duration of 12 to 24 weeks based on cirrhosis status and previous treatment. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. 59
HETLIOZ 20MG CAP Patient is totally blind. 60
JUXTAPID 10MG CAP JUXTAPID 30MG CAP JUXTAPID 5MG CAP KYNAMRO 200MG/ML SYRINGE JUXTAPID 20MG CAP JUXTAPID 40MG CAP JUXTAPID 60MG CAP Untreated LDL greater than 500 mg/dl OR treated LDL greater than or equal to 300 mg/dl. Concurrent use of maximum statin dose (atorvastatin or rosuvastatin) and one other lipid lowering agent (include dates and reasons for discontinuation). For patients with statin intolerance, concurrent use of maximum statin dose not required. Chart documentation showing the most recent full lipid panel, including Apo-B within the past 12 months. Prescribed by, or in consultation with, a Lipidologist, Cardiologist, or an Endocrinologist. 61
HUMIRA PEN - PSORIASIS STARTER PACK 40MG/0.8ML INJ Active serious infection (including tuberculosis) Diagnosis of 1 of the following: A) moderate/severe rheumatoid arthritis and inadequate response, intolerance or contraindication to 1 or more non-biologic disease modifying anti-rheumatic drugs (DMARDs) (hydroxychloroquine, sulfasalazine, methotrexate [MTX], leflunomide, azathioprine, cyclosporine) for at least 3 consecutive months B) moderate/severe polyarticular juvenile idiopathic arthritis and inadequate response, intolerance or contraindication to 1 or more non-biologic DMARD for at least 3 consecutive months C) psoriatic arthritis and inadequate response, intolerance or contraindication to MTX D) ankylosing spondylitis and inadequate response, intolerance or contraindication to 1 or more NSAIDs E) moderate/severe chronic plaque psoriasis (affecting more than 5% of body surface area or crucial body areas such as hands, feet, face, genitals) and inadequate response, intolerance or contraindication to at least 1 of the following: phototherapy (including but not limited to Ultraviolet A with a psoralen [PUVA] and/or retinoids [RePUVA] for at least 1 continuous month) or 1 or more oral systemic treatment (MTX, cyclosporine, acitretin, sulfasalazine) for at least 3 consecutive months F) moderate/severe Crohn's disease and inadequate response, intolerance or contraindication to 2 or more corticosteroids (prednisone, methylprednisolone) or non-biologic DMARDs (azathioprine, MTX, mercaptopurine) G) moderate/severe ulcerative colitis and inadequate response, intolerance or contraindication to 2 or more corticosteroids, 5-ASA (mesalamine, sulfasalazine, balsalazide, olsalazine) or non-biologic DMARDs H) severe hidradenitis suppurativa and inadequate response, intolerance or contraindication to 1 oral antibiotic I) uveitis diagnosed by ophthalmologist, prescribed by/in consultation with ophthalmologist or rheumatologist. Trial and or failure of a combination of 1 systemic corticosteroid with 1 immunosuppressant (MTX, mycophenolate mofetil, azathioprine, cyclosporine) 2 years of age or older for JIA. 6 years or older for pediatric Crohn's disease. 18 years of age or older for all other indications Initial - 16 weeks (CD), 12 weeks (UC), 12 months (others). Renewal - 12 months. Patient has been tested for TB and latent TB has been ruled out or is being treated as per guidelines. For renewal, patient has stable disease or has improved while on therapy (For pjia, reduction in disease flares, improvement in ACR scoring. For RA, improvement in tender/swollen joint count, improvement in ACR scoring. For PsA, improvement in number of swollen/tender joints, pain, stiffness. For AS, improvement in AS symptoms, such as stiffness and back pain. For CD, symptomatic remission. For UC, clinical remission, reduction in steroid use.) 62
63
HUMIRA 10MG/0.2ML SYRINGE HUMIRA 40MG/0.8ML AUTO-INJECTOR HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 40MG/0.8ML IN HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ HUMIRA 20MG/0.4ML SYRINGE HUMIRA 40MG/0.8ML SYRINGE HUMIRA PEDIATRIC CROHN'S STARTER PACK (6) 40MG/0.8ML IN For moderate to severe RA or Psoriatic Arthritis requires intolerance to or failure of therapy with methotrexate (at least 20mg/wk). Plaque Psoriasis: Failure of, or intolerance to, methotrexate at a dose of 15mg/week or failure of, or intolerance to, soriatane. If for Hidradenitis Suppurativa (HS), patient must have at least 3 cysts. Rheumatoid Arthritis, Psoriatic Arthritis and Ankylosing Spondylitis: Prescriber must be a Rheumatologist. All Plaque Psoriasis and Hidradenitis Suppurativa (HS): Prescriber must be a Dermatologist. 64
HYDROXYPROGESTERONE CAPROATE 250MG/ML INJ (New Starts 65
IBRANCE 100MG CAP (New Starts Only) IBRANCE 75MG CAP (New Starts Only) IBRANCE 125MG CAP (New Starts Only) Prescribed by or in consultation with an Oncology Specialist Approved for duration of contract year subject to formulary change and member eligibility 66
ICLUSIG 15MG TAB (New Starts Only) ICLUSIG 45MG TAB (New Starts Only) Prescribed by or in consult with Oncology Specialist. 67
ILARIS 180MG INJ 68
IMBRUVICA 140MG CAP (New Starts Only) Prescribed by an Oncologist or Hemotologist or under the direct consultation of an Oncologist or Hemotologist 69
IMFINZI 120MG/2.4ML INJ (New Starts Only) IMFINZI 500MG/10ML INJ (New Starts Only) Prescribed by, or in consultation with an Oncologist. 70
INCRELEX 40MG/4ML INJ For the long-term treatment of growth failure in children with severe primary insulin-like growth factor-1 (IGF-1) deficiency (primary IGFD) or with growth hormone (GH) gene deletion who have developed neutralizing antibodies to GH. 71
INLYTA 1MG TAB (New Starts Only) INLYTA 5MG TAB (New Starts Only) Covered Uses All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D Restricted to or in consult with Oncology Specialist. Covered for duration of plan year subject to formulary change and member eligibility. 72
ESBRIET 267MG CAP ESBRIET 801MG TAB OFEV 150MG CAP ESBRIET 267MG TAB OFEV 100MG CAP Definitive diagnosis of idiopathic pulmonary fibrosis defined by the following: No known cause of lung fibrosis AND one of the following: A. Surgical lung biopsy revealing histopathological pattern of unspecified interstitial pneumonia (UIP) B. High-resolution computed tomography indicates definite UIP pattern C. High-resolution computed tomography indicates possible UIP pattern AND surgical lung biopsy reveals a histopathological pattern of probable UIP Prescribed by a Pulmonology Specialist or in consultation with a Pulmonology Specialist. Will not be used in combination with other medications used to treat IPF. 73
IRESSA 250MG TAB (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 74
ISTODAX 10MG INJ (New Starts Only) Prescribed by or consultation with Hematologist or Oncologist Approval subject to BvD determination 75
itraconazole 100mg cap For onychomycosis or diffuse dermatologic fungal infections: 1. If not prescribed by a Dermatologist or Podiatrist OR fungal infection is confirmed by a positive KOH test. 2. For onychomycosis, must fail terbinafine. For dermatologic infections, must fail one topical antifungal medication. Infectious Disease Specialists, Pulmonologist or Dermatologist or have consulted with an Infectious Disease Specialist, Pulmonologist or Dermatologist concerning the patient. Approved for 6 months. 76
BIVIGAM 10% INJ FLEBOGAMMA 10% INJ GAMASTAN 180UNIT/ML INJ GAMMAGARD 10GM INJ GAMMAGARD 5GM INJ GAMMAPLEX 10GM/100ML INJ GAMMAPLEX 20GM/200ML INJ GAMUNEX 1GM/10ML INJ OCTAGAM 2GM/20ML INJ CARIMUNE 6GM INJ GAMASTAN 1800UNIT/10ML INJ GAMASTAN 360UNIT/2ML INJ GAMMAGARD 2.5GM/25ML INJ GAMMAKED 1GM/10ML INJ GAMMAPLEX 10GM/200ML INJ GAMMAPLEX 5GM/50ML INJ OCTAGAM 25GM/500ML INJ PRIVIGEN 20GM/200ML INJ Approval will be based off BvD coverage determination. 77
JAKAFI 10MG TAB (New Starts Only) JAKAFI 20MG TAB (New Starts Only) JAKAFI 5MG TAB (New Starts Only) JAKAFI 15MG TAB (New Starts Only) JAKAFI 25MG TAB (New Starts Only) Covered Uses All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D. Restricted to or in consult with Oncology or Hematology Specialist. 78
KADCYLA 100MG INJ (New Starts Only) Approval will be based off BvD coverage determination. 79
KALYDECO 150MG TAB KALYDECO 75MG GRANULES PACKET KALYDECO 50MG GRANULES PACKET Covered Uses All FDA-approved indications not otherwise excluded from Part D. All medically accepted indications not otherwise excluded from Part D Restricted to or in consult with Pulmonology Specialist. Covered for duration of plan year subject to formulary change and member eligibility. 80
KEYTRUDA 100MG/4ML INJ (New Starts Only) KEYTRUDA 50MG INJ (New Starts Only) Prescribed by or in consult with Oncology Specialist. 81
KINERET 100MG/0.67ML SYRINGE Covered Uses All medically accepted indications not otherwise excluded from Part D. If for the treatment of RA, trial or contraindication to Enbrel and Humira. Prescribed by a Rheumatologist (All Indications). If for Cryopyrin-Associated Periodic Syndromes (CAPS), Prescribed by a Rheumatologist or Pediatrician. 82
KORLYM 300MG TAB Covered Uses All FDA-approved indications not otherwise excluded by Part D. 83
KUVAN 100MG POWDER FOR ORAL SOLN KUVAN 500MG POWDER FOR ORAL SOLN KUVAN 100MG TAB For continuing therapy the patient must have shown a 20% drop in Phenylalanine levels after 2 months of Kuvan treatment. Prescribed by a Medical Geneticist or Metabolic Specialist. Initial = 3 months, then if critieria is met approved for the rest of the plan year. 84
KYPROLIS 30MG INJ (New Starts Only) KYPROLIS 60MG INJ (New Starts Only) Prescribed by, or in consultation with an Oncologist or Hematologist 85
LARTRUVO 10MG/ML INJ (New Starts Only) Prescribed by, or in consultation with an Oncologist. 86
LENVIMA (8) 4MG PACK (New Starts Only) LENVIMA 14 PACK (New Starts Only) LENVIMA 20 10MG PACK (New Starts Only) LENVIMA 10 10MG PACK (New Starts Only) LENVIMA 18 PACK (New Starts Only) LENVIMA 24 PACK (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 87
LETAIRIS 10MG TAB LETAIRIS 5MG TAB Diagnosis confirmed by right heart catheterization. Restricted to or in consult with Pulmonologist or Cardiologist. 88
lidocaine 5% patch Covered Uses All FDA-approved indications not otherwise excluded from Part D. Management of neuropathic pain associated with diabetic peripheral neuropathy and postherpetic neuralgia. Trial and failure of gabapentin of four weeks or more 89
LINZESS 145MCG CAP LINZESS 72MCG CAP LINZESS 290MCG CAP 90
LONSURF 15-6.14MG TAB (New Starts Only) LONSURF 20-8.19MG TAB (New Starts Only) Prescribed by an Oncology Specialist or in consultation with an Oncology Specialist. 91
LYNPARZA 50MG CAP (New Starts Only) Restricted to Oncology Specialist or in consult with Oncology Specialist. 92
megestrol acetate 40mg/ml susp 93
megestrol acetate 20mg tab (New Starts Only) megestrol acetate 40mg tab (New Starts Only) 94
MEKINIST 0.5MG TAB (New Starts Only) MEKINIST 2MG TAB (New Starts Only) Prescribed by or in consult with an Oncology Specialist. 95
MOVANTIK 12.5MG TAB MOVANTIK 25MG TAB Initial Therapy: Member must meet all criteria. 1. Opioid-induced constipation. 2. Failed two laxative/bowel therapies -- polyethylene glycol and lactulose. 4 Months 96
ABELCET 5MG/ML INJ acetylcysteine 20% inh soln adriamycin 2mg/ml inj AKYNZEO 300-0.5MG CAP albuterol 0.417mg/ml (1.25mg/3ml) inh soln albuterol 1mg/ml (0.5%) inh soln AMINOSYN 7% WITH ELECTROLYTES, SULFITE-FREE INJ AMINOSYN II 10% INJ AMINOSYN II 8.5%, SULFITE-FREE INJ AMINOSYN-PF 10%, SULFITE-FREE INJ AMINOSYN-RF 5.2%, SULFITE-FREE INJ aprepitant 125mg cap aprepitant 40mg cap ARANESP 100MCG/0.5ML SYRINGE ARANESP 10MCG/0.4ML SYRINGE ARANESP 200MCG/0.4ML SYRINGE ARANESP 25MCG/0.42ML SYRINGE ARANESP 300MCG/0.6ML SYRINGE ARANESP 40MCG/0.4ML SYRINGE ARANESP 500MCG/ML SYRINGE ARANESP 60MCG/ML INJ ASTAGRAF 1MG XL CAP ATGAM 50MG/ML INJ AZASAN 75MG TAB azathioprine 50mg tab bleomycin 15unit/ml inj budesonide 0.125mg/ml inh soln budesonide 0.5mg/ml inh soln calcitriol 0.0005mg cap acetylcysteine 10% inh soln acyclovir 50mg/ml inj adrucil 500mg/10ml inj albuterol 0.21mg/ml (0.63mg/3ml) inh soln albuterol 0.83mg/ml (0.083%) inh soln AMBISOME 50MG INJ aminosyn 8.5% with electrolytes, sulfite-free inj aminosyn ii 8.5% with electrolytes, sulfite-free inj AMINOSYN-HBC 7%, SULFITE-FREE INJ AMINOSYN-PF 7% INJ AMPHOTERICIN B 50MG INJ aprepitant 125mg/80mg pack aprepitant 80mg cap ARANESP 100MCG/ML INJ ARANESP 150MCG/0.3ML SYRINGE ARANESP 200MCG/ML INJ ARANESP 25MCG/ML INJ ARANESP 300MCG/ML INJ ARANESP 40MCG/ML INJ ARANESP 60MCG/0.3ML SYRINGE ASTAGRAF 0.5MG XL CAP ASTAGRAF 5MG XL CAP AZASAN 100MG TAB AZATHIOPRINE 10MG/ML INJ BCG, LIVE, TICE STRAIN 50MG/ML INJ BOOSTRIX INJ budesonide 0.25mg/ml inh soln calcitriol 0.00025mg cap calcitriol 0.001mg/ml inj 97
calcitriol 0.001mg/ml oral soln cladribine 1mg/ml inj CLINIMIX 4.25/20 INJ CLINIMIX 4.25/5 INJ CLINIMIX 5/20 INJ CLINIMIX E 2.75/10 INJ CLINIMIX E 4.25/10 INJ CLINIMIX E 4.25/5 INJ CLINIMIX E 5/20 INJ clinisol 15% inj CYCLOPHOSPHAMIDE 25MG CAP cyclosporine 100mg cap cyclosporine 50mg/ml inj cyclosporine, modified 100mg/ml oral soln CYCLOSPORINE, MODIFIED 50MG CAP CYTARABINE 20MG/ML INJ doxercalciferol 0.0005mg cap doxercalciferol 0.0025mg cap doxorubicin 2mg/ml inj duramorph 1mg/ml inj EMEND 40MG CAP EMEND TRI-FOLD PACK ENGERIX-B 10MCG/0.5ML SYRINGE ENVARSUS 0.75MG ER TAB ENVARSUS 4MG ER TAB EPOGEN 20000UNIT/ML INJ EPOGEN 3000UNIT/ML INJ fluorouracil 50mg/ml inj ganciclovir 500mg inj gengraf 100mg/ml oral soln CELLCEPT 500MG INJ CLINIMIX 4.25/10 INJ CLINIMIX 4.25/25 INJ CLINIMIX 5/15 INJ CLINIMIX 5/25 INJ CLINIMIX E 2.75/5 INJ CLINIMIX E 4.25/25 INJ CLINIMIX E 5/15 INJ CLINIMIX E 5/25 INJ CROMOLYN SODIUM 10MG/ML INH SOLN CYCLOPHOSPHAMIDE 50MG CAP cyclosporine 25mg cap cyclosporine, modified 100mg cap cyclosporine, modified 25mg cap cytarabine 100mg/ml inj DIPHTHERIA/TETANUS TOXOID INJ doxercalciferol 0.001mg cap doxercalciferol 0.002mg/ml inj duramorph 0.5mg/ml inj EMEND 125MG CAP EMEND 80MG CAP ENGERIX-B 10MCG/0.5ML INJ ENGERIX-B 20MCG/ML SYRINGE ENVARSUS 1MG ER TAB EPOGEN 10000UNIT/ML INJ EPOGEN 2000UNIT/ML INJ EPOGEN 4000UNIT/ML INJ FREAMINE 6.9% INJ gengraf 100mg cap gengraf 25mg cap 98
gengraf 50mg cap glucose 5% inj granisetron 1mg tab heparin sodium, porcine 1000unit/ml inj heparin sodium, porcine 20000unit/ml inj heparin sodium, porcine 5000unit/ml inj HEPATAMINE 8% INJ HYPERRAB 150UNIT/ML (2ML) INJ IMOGAM 150UNIT/ML (2ML) INJ intralipid 20% inj ipratropium/albuterol 0.5-2.5mg/3ml inh soln levalbuterol 0.63mg inh soln levalbuterol 2.5mg inh soln levocarnitine 330mg tab methylprednisolone 62.5mg/ml inj MORPHINE SULFATE 2MG/ML SYRINGE mycophenolate mofetil 250mg cap mycophenolate mofetil 500mg tab mycophenolic acid 360mg dr tab NEPHRAMINE 5.4% INJ ondansetron 0.8mg/ml oral soln ondansetron 4mg odt ondansetron 8mg odt pamidronate disodium 3mg/ml inj pamidronate disodium 9mg/ml inj paricalcitol 0.002mg cap paricalcitol 0.004mg cap PENTAM 300MG INJ PREMASOL 10% INJ PROCALAMINE 3% INJ glucose 10% inj glycopyrrolate 0.2mg/ml inj heparin sodium, porcine 10000unit/ml inj HEPARIN SODIUM, PORCINE 100UNIT/ML INJ heparin sodium, porcine 40unit/ml inj heparin sodium, porcine 50unit/ml inj HYPERRAB 150UNIT/ML (10ML) INJ ibandronate 1mg/ml inj IMOVAX 2.5UNIT/ML INJ ipratropium bromide 0.02% inh soln levalbuterol 0.31mg inh soln levalbuterol 1.25mg inh soln levocarnitine 100mg/ml oral soln methylprednisolone 40mg/ml inj MIACALCIN 200UNIT/ML INJ mycophenolate mofetil 200mg/ml susp mycophenolate mofetil 500mg inj mycophenolic acid 180mg dr tab NEBUPENT 300MG INH SOLN nutrilipid 20% iv soln ondansetron 24mg tab ondansetron 4mg tab ondansetron 8mg tab PAMIDRONATE DISODIUM 6MG/ML INJ paricalcitol 0.001mg cap paricalcitol 0.002mg/ml inj paricalcitol 0.005mg/ml inj plenamine 15% inj premasol 6% inj PROCRIT 10000UNIT/ML INJ 99
PROCRIT 20000UNIT/ML INJ PROCRIT 3000UNIT/ML INJ PROCRIT 4000UNIT/ML INJ PROSOL 20% INJ RABAVERT 2.5UNIT/ML INJ RECOMBIVAX 10MCG/ML SYRINGE RECOMBIVAX 5MCG/0.5ML SYRINGE REMODULIN 10MG/ML INJ REMODULIN 2.5MG/ML INJ SANDIMMUNE 100MG/ML ORAL SOLN sirolimus 0.5mg tab sirolimus 2mg tab tacrolimus 1mg cap TENIVAC SYRINGE THYMOGLOBULIN 25MG INJ TROPHAMINE 10% INJ VARUBI 90MG TAB vincasar 1mg/ml inj ZARXIO 300MCG/0.5ML SYRINGE PROCRIT 2000UNIT/ML INJ PROCRIT 40000UNIT/ML INJ PROGRAF 5MG/ML INJ PULMOZYME 1MG/ML INH SOLN RAPAMUNE 1MG/ML ORAL SOLN RECOMBIVAX 40MCG/ML INJ RECOMBIVAX HB 10MCG/ML INJ REMODULIN 1MG/ML INJ REMODULIN 5MG/ML INJ SIMULECT 20MG INJ sirolimus 1mg tab tacrolimus 0.5mg cap tacrolimus 5mg cap TETANUS/DIPHTHERIA TOXOID INJ TRAVASOL 10% INJ TWINRIX INJ VINBLASTINE 1MG/ML INJ vincristine sulfate 1mg/ml inj ZARXIO 480MCG/0.8ML SYRINGE Covered Uses This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 100
101
NATPARA 100MCG CARTRIDGE NATPARA 50MCG CARTRIDGE NATPARA 25MCG CARTRIDGE NATPARA 75MCG CARTRIDGE Prescribed by or in consult with Endocrinologist. 102
NEULASTA 6MG/0.6ML SYRINGE For use as primary prophylaxis of febrile neutropenia (FN) in one of the following patients: A) Patient has a 20% or higher risk of FN based on chemotherapy regimen OR B) Patient has 10% to less than 20% risk of developing FN based on chemotherapy regimen AND at least one of the following risk factors are present: 65 years or older, Poor performance status, Poor nutritional status, Previous episodes of febrile neutropenia, Extensive prior treatment including large radiation ports, Cytopenias due to bone marrow involvement by tumor, Administration of combined chemoradiotherapy, Presence of open wounds or active infections, Other serious comorbidities (including renal or liver dysfunction notably elevated bilirubin), or C) patient has less than 10% risk of developing FN based on chemotherapy regimen AND the intent of treatment is curative or adjuvant and patient is at risk for serious medical consequences of FN, including death and patient is receiving myelosuppressive chemotherapy regimen for a non-myeloid malignancy, or D) For use as secondary prophylaxis of FN in a patient who had a neutropenic complication from a prior cycle of chemotherapy (for which primary prophylaxis was not received) 12 months 103
NEXAVAR 200MG TAB (New Starts Only) Require patient to be at least 18 years old. Prescribed by a Oncologist or under the direct consultation of an Oncologist. 104
NINLARO 2.3MG CAP (New Starts Only) NINLARO 4MG CAP (New Starts Only) NINLARO 3MG CAP (New Starts Only) Prescribed by an Oncology Specialist or Hematology Specialist, or in consultation with an Oncology Specialist or Hematology Specialist. 105
NORTHERA 100MG CAP NORTHERA 300MG CAP NORTHERA 200MG CAP Prescribed by, or in consultation with, a Neurology Specialist or Cardiologist. 106
NOXAFIL 100MG DR TAB NOXAFIL 40MG/ML SUSP 107
NUCALA 100MG INJ Peripheral blood eosinophil count of greater than or equal to 150 cells per microliter. History of 2 or more exacerbations in the previous year despite regular use of high-dose inhaled corticosteroids plus an additional controller(s). An exception is made for patients with intolerance or contraindication to high-dose inhaled corticosteroids and additional controller(s). Member must be at least 12 years old. Prescribed by, or in consultation with, an Allergy Specialist, Immunologist, or Pulmonary Specialist. 108
NUEDEXTA 20-10MG CAP 109
NULOJIX 250MG INJ (New Starts Only) Medication will be used for the prevention of kidney transplant organ rejection AND the patient is immune to the Epstein-Barr virus (EBV seropositive) AND the patient is prescribed concurrent therapy with mycophenolate and corticosteroids. 18 years of age or older Prescriber is experienced in immunosuppressive therapy and management of transplant patients 12 months Part B if transplant covered by Medicare. otherwise Part D 110
NUPLAZID 17MG TAB (New Starts Only) 111
armodafinil 150mg tab armodafinil 250mg tab modafinil 100mg tab NUVIGIL 200MG TAB armodafinil 200mg tab armodafinil 50mg tab modafinil 200mg tab Diagnosis of narcolepsy, OR obstructive sleep apnea/hypopnea syndrome, OR shift work sleep disorder 112
OCALIVA 10MG TAB OCALIVA 5MG TAB Prescribed by, or in consultation with a Hepatologist or Gastroenterologist For use in treatment of primary biliary cholangitis, patient has had an inadequate response to a year of therapy with ursodiol or experienced intolerance to ursodiol. 113
ODOMZO 200MG CAP (New Starts Only) Prescribed by or inconsultation with Oncology Specialist or Dermatologist. 114
ONFI 10MG TAB (New Starts Only) ONFI 20MG TAB (New Starts Only) ONFI 2.5MG/ML SUSP (New Starts Only) Covered Uses All FDA Approved indications not otherwise excluded from Part D. 115
OPDIVO 40MG/4ML INJ (New Starts Only) Restricted to Oncology Specialist or in consult with Oncology Specialist. 116
OPSUMIT 10MG TAB Diagnosis confirmed by right heart catheterization. Restricted to or in consult with Pulmonologist or Cardiologist. 117
fentanyl 0.2mg lozenge fentanyl 0.6mg lozenge fentanyl 1.2mg lozenge LAZANDA 100MCG/ACT NASAL SPRAY LAZANDA 400MCG/ACT NASAL SPRAY fentanyl 0.4mg lozenge fentanyl 0.8mg lozenge fentanyl 1.6mg lozenge LAZANDA 300MCG/ACT NASAL SPRAY Breakthrough cancer pain and opioid tolerence. Documented tolerance to opioids defined as patients taking around the clock medicine consisting of at least 60mg of oral morphine daily, at least 25mcg of transdermal fentanyl per hour, at least 30mg of oxycodone daily, at least 8mg of oral hydromorphone daily, or an equianalgesic dose of another opioid daily for a week or longer. 118
ORENCIA 50MG/0.4ML SYRINGE ORENCIA 87.5MG/0.7ML SYRINGE For moderate to severe RA intolerance to or failure of therapy with Enbrel OR Humira. For Polyarticular Juvenile Idiopathic Arthritis intolerance to or failure of therapy with Enbrel. Prescribed by or in consultation with Rheumatology Specialist. 119
ORFADIN 10MG CAP ORFADIN 5MG CAP ORFADIN 2MG CAP 120
ORKAMBI 100-125MG TAB ORKAMBI 200-125MG TAB 1) Lung function (FEV1, ppfev1), 2) BMI, 3) Pulmonary exacerbation history to be collected initially and at continuation. Prescribed by, or in consultation with, pulmonologist. Initial and continuation approval of 6 months to assess required medical info 121
oxandrolone 10mg tab oxandrolone 2.5mg tab Breast or prostate cancer in men. Breast cancer in women with hypercalcemia. Pregnancy. Nephrosis or nephrotic phase of nephritis. Hypercalcemia. Patient is receiving treatment as an adjunct therapy to promote weight gain and has one of the following: Extensive surgery, Chronic infections, Severe trauma, Failure to gain or maintain at least 90% of ideal body weight without definite pathophysiologic reasons and Patient has had an inadequate response, intolerance, or contraindication to nutritional supplements and a nutritional consult was performed OR Oxandrin (oxandrolone) will be used to counterbalance protein catabolism associated with chronic corticosteroid administration OR Patient has bone pain associated with osteoporosis. Osteoporosis bone pain: 1 month. Other diagnoses: 3 months For renewal, patient has experienced an objective improvement (i.e. weight gain, increase in lead body mass, or reduction in muscle pain/weakness) 122
PRALUENT 150MG/ML AUTO-INJECTOR REPATHA 120MG/ML CARTRIDGE REPATHA 140MG/ML SYRINGE PRALUENT 75MG/ML AUTO-INJECTOR REPATHA 140MG/ML AUTO-INJECTOR For initiation of therapy patient must: A) have one of the following conditions: 1) prior clinical atherosclerotic cardiovascular disease (ASCVD) (see ), 2) heterozygous familial hypercholesterolemia (HeFH) (see Other Criteria), or 3) homozygous familial hypercholesterolemia (HoFH) (see ), AND B) for patients with prior clinical ASCVD or HeFH, current LDL-C level is over 100 mg/dl or over 70 mg/dl with diabetes, AND one of the following requirements is met: 1) patient has been treated for 8 weeks or more with a high intensity statin (atorvastatin 40mg or greater OR rosuvastatin 20mg or greater) in combination with ezetimibe, OR 2) patient is intolerant to statins demonstrated by the failure of 2 statins in combination with ezetimibe, including an attempt with a low- or alternatively-dosed statin (twice weekly low-dose rosuvastatin or atorvastatin, low-intensity pitavastatin or pravastatin). For continuation of therapy, patient must: A) have one of the following conditions: 1) prior clinical ASCVD (see ), 2) HeFH (see ), or 3) HoFH (see ), AND B) demonstrate a reduction of LDL-C on PCSK9 inhibitor therapy. Prescribed by or in consultation with a Cardiologist, Lipidologist, or Endcrinologist Clinical ASCVD defined as acute coronary syndromes, myocardial infarction, stable or unstable angina, coronary or other arterial revascularization procedure, prior stroke or transient ischemic attack, or peripheral arterial disease of presumed atherosclerotic origin. Diagnosis of HeFH must be confirmed by one of the following: 1) DNA-based evidence of mutation in the LDLR, Apo B, OR PCSK9 gain of function mutation, 2) Untreated LDL-C greater than 190 mg/dl AND tendon xanthomas in patient or first/second degree relative, 3) Untreated LDL-C greater than 190 mg/dl AND either first degree relative less than 60 years of age or second degree relative less than 50 years of age with premature heart disease, OR 4) untreated LDL-C greater than 190 mg/dl AND first or second degree relative with total cholesterol greater than 290 mg/dl. Diagnosis of HoFH confirmed by the following: 1) two parents diagnosed with HeFH OR genetic confirmation of LDL 123
receptor mutation, AND 2) untreated total cholesterol greater 290 mg/dl or LDL-C greater 190 mg/dl, AND 3) either xanthomas present at 10 years of age or younger OR atherosclerotic disease at 20 years of age or younger. 124
PERJETA 420MG/14ML INJ (New Starts Only) Prescribed by, or in consultation with, an Oncologist or Hematology Specialist. 125
POMALYST 1MG CAP (New Starts Only) POMALYST 3MG CAP (New Starts Only) POMALYST 2MG CAP (New Starts Only) POMALYST 4MG CAP (New Starts Only) Covered Uses All FDA-approved indications not otherwise excluded by Part D. Prescribed by, or in consultation with, an Oncologist or Hematology Specialist. 126
CRINONE 4% VAGINAL GEL CRINONE 8% VAGINAL GEL 127
PROMACTA 12.5MG TAB PROMACTA 50MG TAB PROMACTA 25MG TAB PROMACTA 75MG TAB 128
RAVICTI 1.1GM/ML ORAL SOLN Requires trial of sodium phenylbutyrate powder. Prescribed by, or in consultation with, a Metabolic Specialist or Geneticist. 129
RELISTOR 12MG/0.6ML INJ RELISTOR 8MG/0.4ML SYRINGE RELISTOR 12MG/0.6ML SYRINGE Initial Therapy: Member must meet both of the following: 1.Opioid-induced constipation. 2. Trial, or intolerance to, 2 laxative/bowel therapies -- polyethylene glycol + Lactulose. 4 Months 130
INFLECTRA 100MG INJ REMICADE 100MG INJ For the treatment of RA member must have tried and failed Enbrel and Humira. For the treatment of Plaque Psoriasis, Psoriatic Arthritis or ankylosing spondylitis must have tried and failed Enbrel and Humira. For the treatment of Crohn's Disease must have tried and failed Humira. Rheumatoid Arthritis require the patient to be at least 18 years of age. Rheumatoid Arthritis, Psoriatic Arthritis, Reactive Arthritis and Ankylosing Spondylitis= prescriber must be a Rheumatologist. Crohn's Disease or Ulcerative Colitis= prescriber must be a Gastroenterologist. Plaque Psoriasis= prescriber must be a Dermatologist. For members with Ulcerative Colitis additional required medical information is not required. 131
sildenafil 20mg tab Diagnosis confirmed by right heart catheterization. 132
REVLIMID 10MG CAP (New Starts Only) REVLIMID 2.5MG CAP (New Starts Only) REVLIMID 25MG CAP (New Starts Only) REVLIMID 15MG CAP (New Starts Only) REVLIMID 20MG CAP (New Starts Only) REVLIMID 5MG CAP (New Starts Only) Restricted to or in consult with Oncologist or Hematologist. 133
KISQALI 200MG DAILY DOSE PACK (New Starts Only) KISQALI 600MG DAILY DOSE PACK (New Starts Only) KISQALI/FEMARA TAB CO-PACK 400MG (New Starts Only) KISQALI 400MG DAILY DOSE PACK (New Starts Only) KISQALI/FEMARA TAB CO-PACK 200MG (New Starts Only) KISQALI/FEMARA TAB CO-PACK 600MG (New Starts Only) Prescribed by, or in consultation with an Oncologist. Approved for duration of contract year subject to formulary change and member eligibility 134
RUBRACA 200MG TAB (New Starts Only) RUBRACA 300MG TAB (New Starts Only) Prescribed by, or in consultation with an Oncologist. 135
RYDAPT 25MG CAP (New Starts Only) Prescribed by, or in consultation with an Oncologist. 136
SABRIL 500MG ORAL SOLN (New Starts Only) SABRIL 500MG TAB (New Starts Only) Prescribed by, or in consultation with, a Neurologist 137
SAVELLA 100MG TAB SAVELLA 25MG TAB SAVELLA 50MG TAB SAVELLA 12.5MG TAB SAVELLA 4-WEEK TITRATION PACK Use of monoamine oxidase inhibitors concomitantly or within 14 days. Diagnosis of fibromyalgia AND patient had a previous trial with or has a contraindication, intolerance, or allergy to one of the following agents used for the treatment of fibromyalgia: tricyclic antidepressant, SNRI, SSRI, gabapentin. 18 years of age or older 12 months For renewal patient had an improvement in pain, physical functioning, etc. 138
SIGNIFOR 0.3MG/ML INJ SIGNIFOR 0.9MG/ML INJ SIGNIFOR 0.6MG/ML INJ Covered Uses All FDA-approved indications not otherwise excluded by Part D. Prescribed for the treatment of an adult patient with Cushing disease AND Pituitary surgery is not an option OR Pituitary surgery was not curative Prescribed by or in consult with an endocrinologist 139
SIMPONI 100MG/ML AUTO-INJECTOR SIMPONI 50MG/0.5ML AUTO-INJECTOR SIMPONI ARIA 50MG/4ML INJ SIMPONI 100MG/ML SYRINGE SIMPONI 50MG/0.5ML SYRINGE For moderate to severe RA, Psoriatic Arthritis, and ankylosing arthritis intolerance to or failure of therapy with Enbrel AND Humira. Prescribed by a Rheumatology Specialist, Gasteroenterologist or Dermatologist. 140
simvastatin 80mg tab Active liver disease. Pregnancy. Nursing. Patient is taking or initiating therapy with strong CYP3A4 inhibitors (i.e., itraconazole, ketoconazole, posaconazole, protease inhibitors, erythromycin, clarithromycin, telithromycin, and nefazodone), gemfibrozil, cyclosporine, and danazol. Patient has been taking simvastatin 80 mg chronically (12 months or more) without evidence of muscle toxicity AND, if patient is of Chinese descent, they are not concurrently receiving lipid-modifying doses (at least 1 gram/day) of niacin-containing products 12 months 141
SIRTURO 100MG TAB Prescribed by, or in consultation with, an infectious disease specialist. 142
SIVEXTRO 200MG INJ SIVEXTRO 200MG TAB Restricted to Infectious Disease Specialist or in consult with Infectious Disease Specialist. Approved for 6 months subject to formulary change and member eligibility. 143
SOLTAMOX 10MG/5ML ORAL SOLN (New Starts Only) Covered Uses All FDA-approved indications not otherwise excluded by Part D. 144
SOMAVERT 10MG INJ SOMAVERT 20MG INJ SOMAVERT 30MG INJ SOMAVERT 15MG INJ SOMAVERT 25MG INJ Prescribed by, or in consultation with, an Endocrinologist 145
SOVALDI 400MG TAB Patient is diagnosed with chronic HCV (greater than 6 months) with genotype indicated 2) Current HCV-RNA titer member must be 18 years of age or older Prescribed by, or in consultation with, a Gastroenterologist, Hepatologist, Infectious Disease or Transplant Specialist Coverage of 12 to 48 weeks based on genotype and treatment as defined by current AASLD guidelines. Treatment regimen will be approved based on genotype and previous treatment experience as defined by current AASLD guidelines. 146
SPRITAM 1000MG ODT (New Starts Only) SPRITAM 500MG ODT (New Starts Only) SPRITAM 250MG ODT (New Starts Only) SPRITAM 750MG ODT (New Starts Only) Member must have a trial or contraindication to generic levetiracetam. 147
SPRYCEL 100MG TAB (New Starts Only) SPRYCEL 20MG TAB (New Starts Only) SPRYCEL 70MG TAB (New Starts Only) SPRYCEL 140MG TAB (New Starts Only) SPRYCEL 50MG TAB (New Starts Only) SPRYCEL 80MG TAB (New Starts Only) Prescribed by or in consultation with an Oncologist or Hematologist. 148
STIVARGA 40MG TAB (New Starts Only) Prescribed by or in consult with Oncology Specialist. 149
STRENSIQ 40MG/ML INJ STRENSIQ 80MG/0.8ML INJ Prescribed by, or in consultation with, a Pediatric Endocrinologist, Metabolic Specialist, or Genetic Specialist. 150
SUCRAID 8500UNIT/ML ORAL SOLN 151
SUTENT 12.5MG CAP (New Starts Only) SUTENT 37.5MG CAP (New Starts Only) SUTENT 25MG CAP (New Starts Only) SUTENT 50MG CAP (New Starts Only) Prescribed by or in consult with Oncology Specialist. 152
SYLATRON 200MCG INJ (New Starts Only) SYLATRON 600MCG INJ (New Starts Only) SYLATRON 300MCG INJ (New Starts Only) Prescribed by or in consult with an Oncology Specialist. 153